European Journal of Case Reports in Internal Medicine <p><strong>The&nbsp;<span class="HPblu">European Journal of Case Reports in Internal Medicine</span>&nbsp;</strong>is an official journal of the European Federation of Internal Medicine (EFIM), representing 35 national societies from&nbsp;<a href="">33 European countries</a>.&nbsp;<br><br>The journal’s mission is to promote the best medical practice and innovation in the field of acute and general medicine. It also provides a forum for internal medicine doctors where they can share new approaches with the aim of improving diagnostic and clinical skills in this field.&nbsp;<strong><br><span class="HPblu">EJCRIM&nbsp;</span></strong>welcomes high-quality case reports describing unusual or complex cases that an internist may encounter in everyday practice. The cases should either demonstrate the appropriateness of a diagnostic/therapeutic approach, describe a new procedure or maneuver, or show unusual manifestations of a disease or unexpected reactions. The Journal only accepts and publishes those case reports whose learning points provide new insight, contribute to advancing medical knowledge both in terms of diagnostics and therapeutic approaches. Case reports of medical errors, therefore, are also welcome as long as they provide innovative measures on how to prevent them in the current practice (Instructive Errors).&nbsp;<strong><br></strong>The Journal may also consider brief and reasoned reports on issues relevant to the practice of Internal Medicine, as well as Abstracts submitted to the scientific meetings of acknowledged medical societies.<br><br> <strong>EJCRIM</strong> is peer-reviewed with single-blind review and freely accessible to all.</p> SMC media s.r.l. - Via Giovenale 7, Milan - Italy en-US European Journal of Case Reports in Internal Medicine 2284-2594 <h3>Copyright and Disclosures</h3> <p>Every author must sign a copyright transfer agreement and disclose any financial or professional interest in any company, product, or service mentioned in an article. This authorization includes all submitted text including illustrations, tables, and other related materials.<br> If this submission contains any <strong>material that has been previously published</strong>, this authorization <strong>must also be accompanied</strong> by all necessary Permission to Reproduce Published Material" forms completed by the current copyright owner. If this submission contains any <strong>previously unpublished material</strong> for which the person(s) signing this form <strong>does not own copyright</strong>, an additional "Authorization to Publish" form is required from each corresponding copyright owner.</p> <h3>Copyright Transfer Declaration</h3> <p>(this may be included as a word document with your manuscript submission)<br> I confirm that I am the current copyright owner of the material described above and hereby transfer and assign to the European Journal of Case Reports in Internal Medicine (EJCRIM) all copyrights in and to the material for publication throughout the world, in all forms and media, in English and in any other language(s). Such transfer includes publication in this and all future editions of the publication named above and in any other publications (including slide collections and any other nonprint media) of EJCRIM and gives EJCRIM the sole authority to grant rights for use of the material by others.<br> I waive EJCRIM from any liabilities connected to the incorrect copyright statement.<br>The copyright agreement form can be downloaded <a style="font-weight: bold;" href="/documents/EJCRIM_Copyright_auth.pdf">HERE</a> or requested to the editorial office <a style="font-weight: bold;" href=""></a></p> Chronic Miliarial Gout Associated with Carpal Tunnel Syndrome: A Very Rare Clinical Presentation <div class="page" title="Page 1"> <div class="section"> <div class="layoutArea"> <div class="column"> <p>This case report describes an unusual form of gout, called miliarial gout, in association with carpal tunnel syndrome in a 54-year-old woman. Miliarial gout was first described in 2007 and is a very rare presentation of chronic tophaceous gout. The latter condition can cause carpal tunnel syndrome, but this association has not previously been described in association with miliarial gout. In addition, the authors discuss the use of the parsimony principle in internal medicine whereby a single cause is first sought for different symptoms presenting at the same time.</p> </div> </div> </div> </div> Victoria Sadovici-Bobeica Lucia Mazur-Nicorici Aliona Nicorici Virginia Salaru Natalia Loghin-Oprea Maria Garabajiu Valeriu Istrati Minodora Mazur ##submission.copyrightStatement## 2018-08-08 2018-08-08 10.12890/2018_000926 IgG4-related Aortitis <p>Immunoglobulin G4-related disease (IgG4-RD) is a systemic immune-mediated fibroinflammatory condition characterized by tumefactive lesions that can affect multiple organs. Serum IgG4 levels may be elevated. Early recognition is sometimes difficult but is important to avoid irreversible organ damage. We describe the case of a 28-year-old male patient who presented with a 2-year history of recurrent low-grade fever, night sweats and non-specific manifestations. We eventually diagnosed IgG4-related aortitis by PET-CT scan. The patient was successfully treated with prednisolone and mycophenolate mofetil with complete clinical and radiological resolution.</p> Chun Wa Fong Lin Ian Lio Monica Pon Toi Meng Mok Hou Ng ##submission.copyrightStatement## 2018-07-24 2018-07-24 10.12890/2018_000881 You Can’t Heyde Forever <p>Heyde’s syndrome describes an association between aortic stenosis and a predisposition to bleeding from intestinal angiodysplasia resulting from acquired von Willebrand disease. <br> We present the case of an 82-year-old woman with recurrent intestinal bleeding, severe anaemia and secondary myocardial infarction. Investigation identified ileal angiectasia as the source of haemorrhage. As echocardiography revealed severe aortic stenosis the patient underwent surgical valve replacement. At her 3-month follow-up, the patient reported no new bleeding episodes and her functional status had improved.<br> This case highlights Heyde’s syndrome, an entity probably underdiagnosed despite the high prevalence of aortic stenosis and intestinal angiodysplasia in elderly patients.</p> Pedro Pires Inês Costa Alexandra Raposo ##submission.copyrightStatement## 2018-07-10 2018-07-10 10.12890/2018_000896 Bilateral Third Nerve Palsy in Mirror Aneurysms of the Posterior Communicating Arteries <p><em>Background:</em> Bilateral third cranial nerve palsy has only been reported in a handful of conditions including some with inflammatory, tumoural and vascular causes. An urgent imaging study is mandatory to rule out vascular aetiology, mainly aneurysmal subarachnoid haemorrhage (aSAH). <br> <em>Case presentation:</em> A 28-year-old Hispanic woman presented to the emergency department with a 21-day history of a sudden-onset and severe headache that on three occasions was accompanied by transient loss of awareness, the last episode occurring a week previously. The simple CT image showed minimal bleeding at the level of the perimesencephalic cisterns, with evidence of SAH. An angioCT revealed a 5×6 mm bilobed saccular aneurysm of the right posterior communicating artery and a 2×2 mm saccular aneurysm in the posterior left communicating artery.<br> <em>Conclusions:</em> A mirror aneurysm is found in 2–25% of aSAH cases. To date there is no consensus about the optimal management of patients with these findings.</p> Enrique Gomez-Figueroa Omar Cardenas-Saenz Gerardo Quiñones-Pesqueira Roberto Cervantes-Uribe Juan Manuel Calleja-Castillo ##submission.copyrightStatement## 2018-06-28 2018-06-28 10.12890/2018_000912 Lung Adenocarcinoma with Gingival Metastasis <p>Gingival metastasis of lung cancer is uncommon. We report the case of an 82-year-old male smoker admitted to the pulmonology department with right pleural effusion. A chest computed tomography (CT) scan showed an invasive right hilar tumour, adherent to the superior vena cava, pulmonary artery, main right bronchus, mediastinal pleura and pericardium with lymphangitic carcinomatosis of the right lung. Pleural biopsy revealed pleural metastasis of pulmonary adenocarcinoma, its primary lung origin being confirmed by immunohistochemistry. One month later, the patient developed an ulcerated polypoid gingival mass. Biopsy of this lesion showed a poorly differentiated carcinoma compatible with metastasis from the lung adenocarcinoma. The patient underwent irradiation of the gingival mass at a dose of 30 Gray, but his condition worsened rapidly and he was not fit for chemotherapy. He received palliative treatment and died 2 months after diagnosis of his metastatic lung cancer.</p> Imen Gargouri Benzarti Wafa Hergli Sana Aissa Samia Kanoun-Belajouza Abdelaziz Hayouni Abdelhamid Garrouche Ahmed Abdelghani Mohamed Benzarti ##submission.copyrightStatement## 2018-06-26 2018-06-26 10.12890/2018_000861 Long-term Successful Antibiotic Therapy for Recurrent Aortic Graft Infection <p><em>Objective:</em> To report a case of successful long-term conservative management of a patient with aortic graft infection due to multiple infectious agents. <br><em>Materials and methods:</em> We describe the clinical case and present a review of relevant literature.<br> <em>Results:</em> An 82-year-old man presented with recurrent<em> Escherichia coli</em> bacteraemia. He was diagnosed with an endovascular aortic graft infection. As the patient declined surgery, conservative treatment with daily antibiotic therapy was instituted. We report good clinical results after almost 2 years of treatment and follow-up. <br> <em>Conclusions:</em> The preferred treatment of aortic graft infections is surgical. Conservative management is usually offered to poor surgical candidates and is associated with an unfavourable outcome. However, we report that selected patients may be successfully treated using prolonged antibiotic therapy.</p> Liana Dykman Leore Cohen Micha Rapoport ##submission.copyrightStatement## 2018-06-26 2018-06-26 10.12890/2018_000913 A Rare Case of Spinal Sarcoidosis Presenting as Multiple Bone Marrow Oedematous Lesions <p>Sarcoidosis is a systemic disorder that most commonly affects the lungs. Bone involvement is rare, and spinal involvement is even more rare. The presence of focal lesions of the vertebrae is highly suspicious of advanced malignancy. However, malignant metastatic spread to the spine involves the vertebral cortex rather than the bone marrow itself, a distinction that is often missed and therefore misleading. We describe here a middle-aged woman with multiple focal oedematous lesions of the bone marrow suspected of being advanced malignancy but finally diagnosed as a rare case of spinal sarcoidosis.</p> Anat Bel-ange Sigal Tal Micha Rapoport ##submission.copyrightStatement## 2018-06-21 2018-06-21 10.12890/2018_000907 Life-Saving Combined Heart–Kidney Transplantation in a Previous Sequential Heart and Kidney Transplant Recipient <p><em>Purpose:</em> Solid organ re-transplantation in the context of allograft failure is a challenging clinical and ethical problem. Ideally, solid organ re-transplantation after initial allograft failure should be performed in all recipients, but this is often not clinically or logistically feasible. <br> <em>Methods:</em> This report details what we believe is the first combined heart–kidney transplant in a recipient of a previous sequential heart and kidney transplant. <em>Results:</em> Eight years after a combined heart and kidney transplant after initially receiving a sequential heart and kidney transplant, a 31-year-old man is doing extremely well, with no rejection episodes or significant complications after transplantation.<br> <em>Summary:</em> This case confirms that combined heart and kidney transplantation is a viable option for tackling the complex issue of graft failure in recipients of previous cardiac and renal grafts.</p> Meenal Sharma Chris Anthony Christopher Hayward Andrew Jabbour Anne M Keogh Peter Macdonald Jacob Sevastos ##submission.copyrightStatement## 2018-06-19 2018-06-19 10.12890/2018_000924 A 32-Year-Old Woman with Relapsing Pneumonia <p><em>Introduction:</em> Isolated right pulmonary artery agenesis in an adult patient is an extremely rare condition that requires a high level of suspicion to make the diagnosis. <br> <em>Case Description:</em> A 32-year-old woman presented to the emergency room with a 4-month history of recurrent respiratory infections. Chest radiography and computerized tomography (CT) revealed alveolar opacities on the medium and inferior right lobes. Fibreoptic bronchoscopy with bronchial aspirate was negative on both cytological and microbiological analysis. Due to the persistent of the imaging findings after a full course of a wide-spectrum antibiotic, an angio-CT was performed, revealing a complete stop at the level of the right pulmonary artery. Angiography confirmed the diagnosis of right pulmonary artery agenesis.<br> <em>Discussion:</em> Currently, the patient has no exertional dyspnoea, screening for pulmonary hypertension has so far been negative and no further respiratory infections have occurred. It is important to call attention to a major congenital malformation that may remain asymptomatic until adulthood.</p> Ana Rafaela Araújo Magda Sousa Joel Pinto Susana Cavadas Luís Rodrigues ##submission.copyrightStatement## 2018-06-14 2018-06-14 10.12890/2018_000854 Addison’s Disease Caused by Tuberculosis: Diagnostic and Therapeutic Difficulties <p><em>Objectives:</em> To demonstrate difficulties in diagnosing and treating Addison’s disease caused by tuberculosis.<br> <em>Materials and methods:</em> We present a clinical case and review of the literature.<br> <em>Results:</em> A 62-year-old man presented with gastrointestinal symptoms, weight loss and enlarged adrenal glands. After 2 months of diagnostic tests, a working diagnosis of Addison’s disease due to extrapulmonary tuberculosis was made. Treatment was challenging due to interaction between rifampicin and steroids. <br> <em>Conclusion:</em> Our case illustrates that in non-endemic countries, extrapulmonary tuberculosis still needs to be considered as a possible cause of Addison’s disease.</p> Sanne van Haren Noman Hannah Visser Alex Muller Gijs Limonard ##submission.copyrightStatement## 2018-06-12 2018-06-12 10.12890/2018_000911